10050130CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23500 CRISTO RAY DR UNIT ARTS
CONTRACTOR:
PERMIT NO: 10050130
CRFTS
OWNER'S NAME:
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PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
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BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. t! "�`I' [ J ZZ�
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Contractor LIMA ?o �� d.{�! �y Date � �
MECH RESIDENTIAL COMMERCIAL
JOB DESCRIPTION: REMODEL 580SQ ARTS & CRAFTS ROOM,
FINISHES,MINOR
I hereby affirm that I am licensed under the provisions of Chapter 9
PLUMBING,REPLACE LIGHTS,MODERNFOLD DOOR;NO RE -ROOF
(commencing with Section 7000) of Division 3 of the Business & Professions
& NO-STRUCTORAL
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $50000
performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as provi ed r by
Section 3700 of the Labor Code, for the performance of the work fo whi this
APN Number: 34254999.ARTSCRFTS
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses may accrue against said City inconsequence of the
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granting of this pe t. A ditionally, the applicant understands and will comply
Issued by:.,, Date:
with all non -point so rce r ulations per the Cupertino Municipal Code, Section
9.18.
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RE -ROOFS:
Signature Date l(�`�
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, 1 agree to remove all new materials for
inspection.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that [ am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532 should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I use pment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the B y ea Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the C er no Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 2 505 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
Owner or authorized agent: Date:�Q
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person inany manner so as to become subject to the Worker's
Compensation laws of Califomia. If, after making this certificate of exemption, I
CONSTRUCTION ENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with al I non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18,
Signature Date